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Laparoscopic Hiatal Hernia Repair
Dr. Chen Key Materials Strattice mesh with 18 gauge needle, marking pen Vicryl tacker Pre-op Have Anesthesia place NG to decompress Have Anesthesia have bougie ready Load pleget onto ticron sutures Operative Steps 1. Make 5mm skin incision just superior and left to umbilicus 2. Place zero degree scope into optical trocar 3. While holding tension with camera, spin trocar down through abdominal wall until you go through through pink rectus -> white posterior sheath. Relax on tension from camera, use only spin until you see yellow omentum/pink bowel. Drop angle so you're parallel with abdomen (white above, pink/yellow below). Gas to 15 mm Hg. Switch to 30 degree scope. 4. Place left lateral 5mm trocar, 3 finger breadths superior to umb, far lateral. 5. Place left subcostal 5 mm trocar, 3 finger breadths lateral from xiphoid. 6. Place right subcostal 5 mm trocar, 3 finger breadths lateral from xiphoid. 7. Place liver retraction 5 mm trocar right upper quadrant 8. Liver retraction: screws into the right side of table (same setup as bookwalter). Hooks onto a metal rod. 9. Using platypus x2 grab broad anti-mesenteric fat of colon to retract out of hernia. 10. Place 5 mm trocar in LLQ. 11. Using endoloop via LLQ, tie a segment of greater omentum (?). Pull tense through LLQ trocar, place clamp to retract. 12. Using ligasure, divide short gastrics on greater curvature of the stomach, heading up towards left crus. Keep 1 cm away from stomach. 13. When you reach crus, you can visualize folds of peritoneum running perpendicular to muscle fibers of cruz. Divide with ligasure until you see muscle fibers. 14. Keep dissection on crus, otherwise can get into vessels from celiac trunk drawn into hernia sac. Then keep dissection outside of sac. Keep the aorta below in mind. 15. Once in plane between crus and hernia sac, continue to sweep away/ligasure areolar tissue outside of hernia sac. 16. No need to remove entire sac, but most of it needs to be dissected to avoid retracting the esophagus/stomach back into chest 17. Dissect circumfrentially around esophagus/stomach up in chest 18. Have anesthesia pass bougie to where you dissected 19. Pass penrose drain around esophagus/stomach. Grasp with locking grasper (marylin). Retract towards the feet. 20. Complete dissection of hernia sac, if not done. 21. Close crus primarily with plegeted ticron sutures: A. straighten needle to fit through trocar B. Grab string with needle holder bring through left subxiphoid, dolphin nose grasper in right subxiphoid C. Load needle intra-abdominally D. Take full bite through right crus, not many muscle fibers and needs good tissue. Grab with left hand, reload without pulling through. Then pull out. E. If needle flipped, grab string with right hand with needle in left, pull up to turn needle. F. Use left hand to push away caudate lobe, take bite through left crus — try to come out at area of peritoneum to add strength to stitch. Careful of IVC behind caudate. Push in, let go with right hand, regrasp with right without moving left retraction. G. Pull out suture, add 2nd pleget, cut needle off. H. Hold constant tension - look at your view to determine necessary tension on string. Put in a two handed throw, then hold both strands in left hand like holding a coffee mug — strands pinched between thumb and index. Use knot pusher to push knot. Repeat x4 throws. 22. Have strattice mesh ready, with keyhole cut for esophagus. Mark circumfrentially with marking pen, stab marks x4-5 with 18G needle. 23. Pass mesh beneath esophagus. Use ticron tacks — don't push in superiorly. Doesn't have to be tight, not strength layer, only to help scar in. 24. Ensure hemostasis/suction fluid. 25. Remove penrose drain 26. Remove endoloop in LLQ 27. Remove trocars under direct vision. Remove trocar of camera port before removing camera, observe layers of abd wall as you pull out scope. 28. Close skin with 4-0 monocryl.